'When you hear hoofbeats, think of horses not zebras' - the old adage is well-known to GPs but what should you do when faced with a zebra, not a horse? Consultant cardiologist Professor Robert Tulloh and GP Dr Louise Tulloh kick off our new series with their advice on how to catch Kawasaki disease in general practice.

'Poor value' QOF indicators identified

A string of QOF indicators are only cost-effective in less than half of practices, according to research that lays bare the NICE methodology for assessing the value for money offered by different clinical indicators in the GP contract.

An economic analysis of nine indicators, including indicators for record-keeping and well-established clinical practice in diabetes, coronary heart disease, hypertension and stroke, found that some were cost-effective in only a third of practices.

The analysis, which the authors told Pulse uses the same methodology NICE is using to r evaluate the cost effectiveness of indicators, offers an insight into which indicators may be under threat when the NICE QOF indicator advisory group recommend which indicators are not delivering good value for money and should be dropped.

Researchers at the University of York combined data from a literature review with an analysis of QOF payments for nine indicators in all practices in England in 2004-5 and calculated the cost-effectiveness of the indicators based on the same £20,000 per quality-adjusted life year (QALY) threshold used by NICE. The study is published in the May issue of the British Journal of General Practice.

And in further analysis obtained by Pulse, the researchers also calculated the proportion of practices in which payments for each of the nine indicators were cost effective at the £20,000 per QALY threshold, assuming a minimum level required for overall cost effectiveness is achieved in all practices.

The QOF DM15 indicator, which rewards for the percentage of diabetic patients with proteinuria or albuminuria who are treated with either an ACE inhibitor or an ARB was cost effective in only 36% of practices.

The stroke 12 QOF indicator, for recording which stroke patients are receiving antiplatelets or anticoagulants also scored lowly, and was cost effective in 40% of practices. On average, the nine indicators studies were cost effective in only 45% of practices.

Mr Simon Walker, a research fellow at the University of York, said: ‘These indicators should be considered in the same vein as health care technologies. They should be subject to the same rigorous approaches in proving that they are value for money to the NHS. The framework we developed is now part of NICE's assessment of new QOF items so should be used routinely moving forward.

But he advised against setting different achievement thresholds for different practices.

‘I think the process of setting different targets for different practices would result in very large administration costs which would most likely outweigh the possible gains from such a policy. There would also be the risk of increased gaming on behalf of GPs if they expected the introduction of indicators which could have adverse effects on quality of care.'

Screening for diabetic retinopathy was better value than other indicators QOF cost-effectiveness

Proportion of practices for which indicator is cost-effective at the £20k per QALY threshold